Pr. Majed ZEMNI Cairo 7-8 December 2011 UNESCO Regional Conference on « Current Challenges in Women’s Health Care and Medical Research »

Introduction The reproductive health is an important component of well physical, mental and social being. Tunisia has undergone significant changes in reproductive health of women in several areas.

Age for marriage The statutory age for marriage is limited to 17 years for the young girl on the condition of their consent. Before 20 years, marriage is subject to the consent of the tutor and mother. This joint authority theoretically allows to avoid the risk of a unilateral decision, but marriage by choice of the tutor is not uncommon.

Sanctions

Prenatal monitoring Coverage rate of prenatal visit increased from 54 % in 1984 to 84.5 % in Essential concept developed and integrated in family planning and more comprehensive approach to reproductive health.

Supervision of pregnancy  There is a protocol for monitoring pregnancy proposed by the Caisse Nationale d'Assurance Maladie (CNAM).  The annual ceiling ambulator vists : 100 dinars over in case of pregnancy.  Ability to support the cost of delivery in the private sector.

Pre-and post-natal vacation Motherhood is recognized as essential social function. No prenatal vacation Public sector : women received maternity leave on full pay for 02 months and the possibility of its extension by 04 months leave on half-pay. Private sector : women received maternity leave of 30 days with 2/3 of salary and the possibility of 30 days extension on medical reason. Costs supported by the CNAM.

Pregnant imprisoned women Law n° , related to the Pregnant or nursing imprisoned women Women prisoners, pregnant or nursing are, during the period of pregnancy and lactation, incarcerated in a suitable space, arranged for this purpose with the medical, psychological and social mother and child. Custody is provided by supervisors in civilian clothes.

Medically assisted procreation Law of August 7th, 2001 on of reproductive medicine. Opinion n°1, 1996 of Tunisian National Committee of Medical Ethics. MAP is a Growing business in Tunisia. Activity supervised by legal text. Guaranteed to be conducted by competent specialists. Be done in Private or public sector.

First ethical requirement : competence Respect of the rules by specialists Improving technics Health safety The law took into account the context of our society (married couple, age of mariage and procreation, gamete donor and surrogate motherhood are banned).

Information and consent is mandatory Of the couple Individual interviews Previous treatment Scientific evolution Success Rate Several attempts Possible effects on health of the mother and the futur newborn Written consent of the couple is compulsory.

The Formular of written consent

Equity The resources allocated Free access

AMP is Supported by the CNAM but with conditions Women under 40 years No living children Three attempts : some of the location (public or private) and whatever the technical Advantages : Promotes reproductive rights even if the couple's resources are limited measure of social Equality (couple underprivileged)

But ethical problems For the law "of reproductive age“ Women under 40 years Menopause 49 years, Life expectancy at 74 years Long attempts intervals Long Waiting time in AMP centers Does not cover the full cost.

HIV serodifferent couple The law provides the couple with HIV to have access to AMP Technical caution

HIV serodifferent couple

Tunisian Code of Medical Ethics obstructed labor Decree N° of 17 May 1993 concerning the Code of Medical Ethics. Article 41 : During prolonged or obstructed labor, the physician should consider himself the only judge of the respective interests of the mother and child without being influenced by family considerations.

Maternal mortality Defined as the death related to pregnancy of a woman from conception to the 42nd day after birth. Good indicator of quality of care especially since these deaths are deemed to be preventable. Mortality rate fell from 68.9 per births in 1994 to 44 in Objectif : 18/100 miles in 2015.

Chalenges A strong regional disparities between coastal regions of the East with 51.6 per one hundred thousand live births against 99.4 for the West The areas most affected are the central east and south. Cultural problem : early marriage and pregnancy, especially repeated and closely spaced ones (declining inTunisia): average age of marriage rose from 19.4 years in 1966 to 27 in 1994.

Abortion Is not a contraceptive and family planning way: be considered as an ultimate solution by the women and especially the doctor (The close of conscience of the physician). Article 40 of Tunisian code of ethics: It can not be performed an abortion except in the cases and conditions provided by law.

Conditions The law punishes illegal abortion or non- medical assisted abortion in order to preserve the mother’s health. Conditions : - 03 first months of pregnancy (12 weeks) - Public hospital or a private clinic - Physician practicing legaly their profession The law gives freedom to the physician became aware of illegal abortion to denunciation or not of the illegal abortion (to protect the health of the mother and encourage her to visit).

Conclusion Tunisia has made progress in the services offering to support health needs of women Several regulations consolidate and protect the rights of women in reproductive health Chalenge : interregional inequality between the different levels of care.